重症肌无力胸腺切除围手术期规范、程序化处理探索  

A protocol for the perioperative management of thymectomy for myasthenia gravis patients

作　　者：柳阳春[1] 章晔[1] 林庆[1] 徐全[1] 陈立如[1] 吴昊[1] 

机构地区：[1]江西省人民医院胸外科,南昌330006

出　　处：《中华胸心血管外科杂志》2017年第3期151-154,共4页Chinese Journal of Thoracic and Cardiovascular Surgery

摘　　要：目的 探讨重症肌无力胸腺切除围手术期规范、程序化处理方案,降低肌无力危象发生率.方法 466例重症肌无力行胸腺切除治疗患者,男207例,女259例,年龄5～77岁.病程12天～18年.症状包括眼睑下垂、复视,或伴有四肢无力、呼吸困难、咳嗽无力、构音障碍、吞咽及咀嚼困难.合并甲状腺机能亢进19例,甲状腺机能减退1例,纯红细胞再生障碍6例,肠激惹症、风湿性关节炎、血小板减少综合征各1例.19例甲状腺亢进中15例胸腺切除术前、4例术后发生.按改良Osserman临床分型,Ⅰ型248例,Ⅱa型58例,Ⅱb型66例,Ⅲ型71例,Ⅳ型23例.血浆置换58例.手术方法：正中全胸骨切口116例,“J”形胸骨上段切口204例,胸腔镜手术146例（其中剑突下入路13例）.结果 围手术期死亡2例（0.42％,2/466）,1例猝死,1例因胸腺转移瘤再手术后呼吸衰竭死亡.肌无力危象13例,发生率2.78％ （13/466）,气管切开6例1.29％（6/466）;血浆置换并发低渗综合征二次开胸止血2例,占58例血浆置换的3.4％.病理诊断：胸腺萎缩3例,胸腺增生272例,胸腺瘤178例,胸腺囊肿13例.结论 重症肌无力胸腺切除围手术期规范化、程序化处理及预防和加强重症肌无力危象的处理是降低手术风险的关键.Objective To develop a standard and procedural protocol for the perioperative management of thymectomy for myasthenia gravis（MG） patients and thus to reduce the incidence of MG crisis.Methods From June 1996 to March 2016,466 MG cases received thymectomy we continuously explored key technologies of surgical treatment for MG 466 patients,there were 209 male cases and 259 female cases,with age ranging from 5 to 77 years and chief complaint history ranging from 12 days to 18 years.Symptoms included drooping eyelids,double vision,weakness,shortness of breath,coughing,dysarthria,and difficulties in swallowing and chewing.According to the modified Osserman classification,there were 248 type Ⅰ MG cases,58 type Ⅱa MG cases,66 type Ⅱb MG cases,71 type Ⅲ MG cases,and 23 type Ⅳ MG cases respectively.116 cases received thymecotomy via full sternotomy,204 cases via ＆quot;J＆quot; type semi-sternotomy,and 146 case via thoracoscopy （including 13 cases via sub-xiphoid approach）.Results Perioperatively one case died of sudden death,another patient died of respiratory failure after the second operation for metastatic thymoma,with a mortality rate of 0.42% （2/466）;13 cases had M G crisis （13/466）;Six cases underwent tracheotomy （6/466）;2 cases had plasmapheresis hypotonic syndrome （accounting for 3.4% in plasmapheresis cases） and were reoperated to stop bleeding.Postoperatively pathological diagnosis was made,including three thymic atrophy cases,272 thymic hyperplasia cases,178 thymoma cases,and 13 thymic cyst cases.Conclusion A standard and procedural protocol for the perioperative management of thymectomy for MG patients can be developed,which can reduce the morbidity of MG crisis and the incidence of tracheotomy.

关 键 词：重症肌无力 胸腺切除 胸外科手术 

分 类 号：R655.7[医药卫生—外科学]